Background and Objective: Corneal neurotization is a novel surgical technique used to restore corneal sensation in patients with neurotrophic keratopathy. Neurotrophic keratopathy is a disorder characterized by dysfunction of the ophthalmic division of the trigeminal nerve, which provides sensory innervation to the cornea. Without sensation, the cornea is at risk of infection, ulceration, perforation, and ultimately, vision loss. Corneal neurotization has emerged as an innovative technique to reinnervate anesthetized corneas by transferring a healthy donor nerve to the affected eye around the corneoscleral limbus. As the field of corneal neurotization rapidly grows, there is a need to synthesize the existing body of literature on corneal neurotization and identify important areas for further research. In this review, we will discuss neurotrophic keratopathy and its current management strategies, followed by an overview of corneal neurotization techniques, outcomes, surgical considerations, and future directions. Methods: PubMed and Google Scholar searches were conducted to retrieve and analyze relevant original papers and reviews on neurotrophic keratopathy and corneal neurotization up until April 2022.Key Content and Findings: Currently, numerous techniques for corneal neurotization exist, including direct nerve transfers, as well as indirect neurotization via interposition nerve grafts. So far, corneal neurotization has been shown to be highly successful in restoring corneal sensation, improving visual acuity,and improving corneal epithelial health. To date, there have been no significant differences in outcomes between direct versus indirect neurotization techniques, different donor nerves, or autologous versus allogeneic interposition grafts. However, there is some evidence that corneal neurotization procedures may be more successful in pediatric patients.Conclusions: Corneal neurotization shows great promise in treating neurotrophic corneas and represents the first management option to date that addresses the underlying pathophysiological mechanism of neurotrophic keratopathy by restoring corneal sensation. As the use of corneal neurotization continues to broaden, additional studies will become important to compare techniques in a systematic manner, with larger sample sizes, as well as standardized outcome measures and follow-up time.
Although amniotic membrane transplantation (AMT) has long been used as an essential surgical technique for ocular surface reconstruction, its role continues to evolve and expand. In the management of numerous ocular surface disorders, ranging from inflammatory to infectious, traumatic to neoplastic, the ability to perform AMT is a valuable addition to the skillset of any ophthalmologist. The purpose of this paper is to provide ophthalmologists with an updated, evidence-based review of the clinical indications for AMT in corneal and conjunctival reconstruction, reviewing its common and even experimental applications known to date. The methods of amniotic membrane preservation, the available commercial amniotic membrane products to date, and future directions for amniotic membrane use, including amniotic membrane extract eye drops (AMEED), are also discussed. It is paramount for ophthalmologists to stay up-to-date on the applications of AMT so as to effectively incorporate this versatile treatment modality into their practice,both in the operating room and in the clinic. By familiarizing the general ophthalmologist with its diverse applications, we hope to motivate general ophthalmologists to incorporate the use of AMT into their clinical practice, or provide guidance on how to recognize when referral to a corneal specialist for amniotic membrane application is prudent.
Conjunctival flaps have previously proven to be effective in preserving the globe for individuals with severe ocular surface disease. Infectious keratitis, neurotrophic keratitis, nontraumatic corneal melts, descemetoceles, perforations, and corneal burns are all indications for this procedure. The flaps promote nutrition, metabolism, structure, and vascularity, as well as reduce pain, irritation, inflammation, and infection. Furthermore, patients avoid the emotional and psychological repercussions of enucleation or evisceration, while requiring fewer postoperative medications and office visits. Currently, fewer flaps are performed due to the emergence of additional therapeutic techniques, such as serum tears, bandage lenses, corneal grafting, Oxervate, amniotic membrane, and umbilical cord grafting. However, despite newer conservative medical methods, conjunctival flaps have been demonstrated to be useful and advantageous. Moreover, future technologies and approaches for globe preservation and sight restoration after prior conjunctival flaps are anticipated. Herein, we review the history, advantages, and disadvantages of various surgical techniques: Gundersen’s bipedicle flap, partial limbal advancement flap, selective pedunculated conjunctival flap with or without Tenon’s capsule, and Mekonnen’s modified inferior palpebral-bulbar conjunctival flap. The surgical pearls and recommendations offered by the innovators are also reviewed, including restrictions and potential complications. Procedures for visual rehabilitation in selective cases after conjunctival flap are reviewed as well.
Abstract: To report a palliative and alternative surgical procedure, allogeneic sclera graft combined with autologous conjunctival flap (ASGACF), employing to repair the large emergent corneal perforation. The detail protocol of the surgical procedure was characterized and four representative cases were reviewed. An allogeneic sclera graft and recipient bed were prepared as the traditional penetrating keratoplasty (PK). And then sutured the sclera graft to the bed with 10-0 nylon suture and covered with a pedicled autologous conjunctival flap in half size. In the follow-up, the ASGACF repaired all of the corneal perforations and restored the integral walls of eyeballs, in spite of one who underwent a second surgery. This surgical procedure provided a palliative method to repair the large emergent corneal perforation while there is the lack of a corneal graft.
Background: To explore the safety and effectiveness of Sclera patch grafts in the management of scleral defects.
Methods: This is a retrospective uncontrolled study. Medical records were retrospectively reviewed for 8 eyes of 8 patients with sclera patch grafts. Two patients had necrotizing scleritis, 2 patients had scleral melting/perforation secondary to thermal burns, 4 patients had scleral staphyloma secondary to surgery. Sclera was reconstructed with allogenic sclera patch grafts, 6 in 8 patients combined autologous conjunctival pedicle flap, 1 patient combined partial medial rectus translocation, 1 patient combined autologous pedicle tenon graft, simultaneously. Treatment outcomes were evaluated using structural integrity, best corrected visual acuity (BCVA), scleritis remission, sclera rejection and melt, and ocular symptoms.
Results: Eight patients were reviewed. In all of these cases, satisfactory anatomic and functional outcomes were achieved. In the at least half a year follow-up, the BCVA of all the eight patients were no worse than that of preoperative. No eye pain, foreign body sensation and other discomforts showed in all the patients, except one woman, who showed sclera rejection and melt 1 month postoperative. In addition, one patient showed high intraocular pressure (28 mmHg), which can be controlled by a kind of medicine.
Conclusions: In this series, sclera patch grafts is an effective method for management scleral defects in the at least half a year following-up. Attention should be paid to the sclera patch rejection and melt post operatively.
Background: To evaluate efficacy and safety of combined pars plana vitrectomy (PPV) and scleral fixated intraocular lens (SFIOL) surgery as a single procedure.
Methods: Retrospective interventional case series done at a tertiary eye care center in Northern India. Eleven patients who underwent combined PPV and SFIOL surgery were included and analyzed retrospectively.
Results: Mean age of the patients was 43.36±15.12 years (range, 22–64 years). Eight were male. Mean baseline best corrected visual acuity (BCVA) was 0.78±0.63 logMAR units while the mean post-operative BCVA at 6 months follow-up was 0.37±0.29 logMAR units, the visual gain being statistically significant (P=0.021). None of the patients had a drop in BCVA with nine patients having final BCVA better than 0.48 logMAR units. Choroidal detachment (CD) was the only notable complication, seen in three patients. Other complications included two cases of intraoperative retinal breaks, a case each of reversible corneal edema, ocular hypertension and cystoid macular edema.
Conclusions: Combined PPV and SFIOL is an efficacious procedure for managing IOL/lens dislocation and aphakia in a single surgery. There may be short-term reversible complications with no impact on final visual gain.
Background: Total lower eyelid defect after eyelid malignancy excision poses a challenge in the surgical management of total lower eyelid reconstruction. We describe a technique of reconstructing total lower eyelid defect, using a skin flap and the residual lower forniceal conjunctiva.
Methods: A retrospective case series review. Five patients had undergone lower eyelid basal cell carcinoma excision. A 3–4 mm margin excision was performed and specimens were sent for paraffin section histological examination. Reconstruction was performed at the same stage, using a skin flap and the residual lower forniceal conjunctiva. A full thickness skin flap is raised from the lateral cheek, with its base at the lateral canthus. Subcutaneous tissues are not included in the skin flap. The lower forniceal conjunctiva is released from the inferior retractors and advanced superiorly to cover the inner surface of the skin flap. The skin flap is transposed to cover the lower eyelid defect and sutured to the soft tissues at the medial end of the defect. The advanced forniceal conjunctiva is sutured to the superior edge of the skin flap forming the new mucocutaneous junction of the eyelid margin.
Results: There were 4 females and 1 male, with a mean age of 74 years (range, 68–80 years). Histological clearance was achieved in all cases. None of the patients developed lagophthalmos, symblepharon or dry eye symptoms. None of the patients required any further revision surgery.
Conclusions: Total lower eyelid defects can be reconstructed using the residual lower fornix conjunctiva and a skin flap.
